Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?

Telias, Irene; Katira, Bhushan; Brochard, Laurent

doi:10.1001/jama.2020.8539

Cited by 110 publications

(94 citation statements)

References 16 publications

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“…The mechanistic benefits of prone positioning may also apply under assisted ventilation with spontaneous breathing, because the lung recruitment accrued by prone positioning may attenuate ‘solid-like’ lung behaviour and reduce effort-dependent regional lung stress. Prone positioning improves oxygenation in spontaneously breathing patients with COVID-19 pneumonia [ 69 ]; it is possible that prone positioning could also reduce the risk of patient self-inflicted lung injury [ 70 ]. Thus, prone positioning might facilitate safe spontaneous breathing and diaphragm-protective ventilation as well as lung protection.…”

Section: Clinical Strategies To Facilitate Lung and Diaphragm-protectmentioning

confidence: 99%

Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

et al. 2020

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Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO 2 removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients’ respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.

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Section: Clinical Strategies To Facilitate Lung and Diaphragm-protectmentioning

confidence: 99%

Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

et al. 2020

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“…25 Conversely, delayed intubation could mean withholding treatment from some patients who may benefit from mechanical ventilation. 26 Early in the COVID-19 pandemic, we adopted a strategy of avoiding early intubation and ventilation where possible, and therefore attempted to prioritise other interventions such as non-invasive respiratory support and awake proning in a dedicated unit. Our data demonstrate that 8.5% of the total admitted COVID-19 cases required HDU support, and 31.8% patients with high oxygen requirements can be managed with CPAP alone and survive to discharge.…”

Section: Open Accessmentioning

confidence: 99%

Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience

et al. 2020

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The SARS-CoV-2 can lead to severe illness with COVID-19. Outcomes of patients requiring mechanical ventilation are poor. Awake proning in COVID-19 improves oxygenation, but on data clinical outcomes is limited. This single-centre retrospective study aimed to assess whether successful awake proning of patients with COVID-19, requiring respiratory support (continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO)) on a respiratory high-dependency unit (HDU), is associated with improved outcomes. HDU care included awake proning by respiratory physiotherapists. Of 565 patients admitted with COVID-19, 71 (12.6%) were managed on the respiratory HDU, with 48 of these (67.6%) requiring respiratory support. Patients managed with CPAP alone 22/48 (45.8%) were significantly less likely to die than patients who required transfer onto HFNO 26/48 (54.2%): CPAP mortality 36.4%; HFNO mortality 69.2%, (p=0.023); however, multivariate analysis demonstrated that increasing age and the inability to awake prone were the only independent predictors of COVID-19 mortality. The mortality of patients with COVID-19 requiring respiratory support is considerable. Data from our cohort managed on HDU show that CPAP and awake proning are possible in a selected population of COVID-19, and may be useful. Further prospective studies are required.

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“…9 In this context, the use of awake prone positioning (awake-PP) during spontaneous breathing in non-intubated patients, could contribute to a reduction of the risk of P-SILI by promoting a more homogeneous distribution of ventilation while improving oxygenation and V/Q matching. 10 Several studies have shown that the combination of awake-PP and HFNO or non-invasive ventilation (NIV) is feasible in patients with severe COVID-19 pneumonia, resulting in an increase in oxygenation or a decrease in the respiratory rate and/or dyspnea. [11][12][13][14][15][16] However, to date, it has not been established whether the combination of HFNO plus awake-PP could prevent the need for invasive MV and decrease the need of ICU resources in COVID-19 patients with ARF.…”

Section: Introductionmentioning

confidence: 99%

Awake Prone Positioning Does Not Reduce the Risk of Intubation in COVID-19 Treated with High-Flow Nasal Oxygen Therapy. A Multicenter, Adjusted Cohort Study

Ferrando

Mellado-Artigas

Gea

et al. 2020

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Background: Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone.Methods: Prospective, multicentre, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June, 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory sequential organ failure assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP.Results: A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO+awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95%CI: 0.53–1.43), p=0.60]. Patients treated with HFNO+awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0-2.5) vs 2 IQR 1.0-3.0] days, (p=0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95%CI: 0.40–2.72), p=0.92].Conclusion: In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

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Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?

Cited by 110 publications

References 16 publications

Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience

Awake Prone Positioning Does Not Reduce the Risk of Intubation in COVID-19 Treated with High-Flow Nasal Oxygen Therapy. A Multicenter, Adjusted Cohort Study

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